Highlights & Basics
- Acne is a common inflammatory disease that peaks in adolescence, but may affect any age group.
- Lesions consist of noninflammatory comedones (whiteheads and blackheads) and inflammatory papules, pustules, nodules, and cysts.
- Systemic effects may also be present with acne fulminans, a rare variant of nodulocystic acne.
- Treatments include topical retinoids, keratolytics, hormonal therapy, and antibiotics; moderate to severe nodulocystic acne may require oral isotretinoin.
Quick Reference
History & Exam
Key Factors
skin lesions
Other Factors
skin tenderness
systemic complaints
Diagnostics Tests
1st Tests to Order
clinical diagnosis
Other Tests to consider
hormonal evaluation
bacterial culture
Treatment Options
ongoing
not hormone-related (not pregnant)
mild acne: comedones only
mild acne: with inflammatory papules/pustules
moderate acne: comedones only
moderate acne: with inflammatory papules/pustules
severe or resistant acne
Definition
Classifications
Commonly accepted
- type (comedonal/papular, pustular/nodulocystic), or
- severity (mild/moderate/moderately severe/very severe).
Simplified classification
- Mild: comedones are the main lesions. Papules and pustules may be present but are small and few in number (generally <10).
- Moderate: moderate numbers (10 to 40) of papules and pustules. Moderate numbers (10 to 40) of comedones are also present. Sometimes mild truncal disease.
- Moderately severe: numerous papules and pustules (40 to 100), usually with many comedones (40 to 100) and the occasional (up to 5) larger, deeper nodular inflamed lesions. Widespread affected areas usually involving face, chest, and back.
- Very severe: nodulocystic acne and acne conglobata with severe lesions; many large, painful nodular/pustular lesions along with many smaller papules, pustules, and comedones.
Investigator's Global Assessment (IGA) severity scale
- Grade 0: clear skin with no inflammatory or noninflammatory lesions
- Grade 1: almost clear; rare noninflammatory lesions with no more than 1 small inflammatory lesion
- Grade 2: mild severity; greater than grade 1; some noninflammatory lesions with no more than a few inflammatory lesions (papules/pustules only, no nodular lesions)
- Grade 3: moderate severity; greater than grade 2; up to many noninflammatory lesions and may have some inflammatory lesions, but no more than 1 small nodular lesion
- Grade 4: severe; greater than grade 3; up to many noninflammatory and inflammatory lesions, but no more than a few nodular lesions.
Leeds technique
Vignette
Common Vignette
Other Presentations
Epidemiology
Etiology
- Sebaceous gland hyperplasia and excess sebum production: sebaceous follicle size and number of lobules per gland are increased in patients with acne.[18] Androgens stimulate sebaceous glands to enlarge and produce more sebum, a process that is most prominent during puberty.
- Abnormal follicular differentiation: in normal follicles, keratinocytes are shed as single cells into the lumen and then excreted. In acne, keratinocytes are retained and accumulate due to their increased cohesiveness.[19]
- Cutibacterium acnes colonization: previously named Propionibacterium acnes, these gram-positive, nonmotile rods are found deep in follicles and stimulate the production of proinflammatory mediators and lipases.[20] While there may be increased numbers of C acnes in acne, bacterial counts often do not correlate with acne severity.[21]
- Inflammation and immune response: inflammatory cells and mediators efflux into the disrupted follicle, leading to the development of papules, pustules, nodules, and cysts.
Pathophysiology
Diagnostic Approach
History
Physical exam
Laboratory evaluation
Risk Factors
History & Exam
Tests
Differential Diagnosis
Differentiating Signs/Symptoms
- Possibly caused (or exacerbated) by oral medications (e.g., steroids, Janus kinase inhibitors), topical corticosteroids, contrast dye, testosterone, and cosmetic products.
- Clinical clues include the abrupt onset of lesions within days of exposure, widespread involvement, atypical locations, atypical age, and improvement with cessation of medication or exposure.
Differentiating Tests
- Clinical differentiation usually suffices.
Differentiating Signs/Symptoms
- Comedones, pustules, and cysts are most commonly found behind the ears and in the axillae and groin.
- Consider exposure to halogenated aromatic hydrocarbons (e.g., chlorinated dioxins and dibenzofurans). Patient may have systemic complications such as ophthalmic, neuropathic, hepatic, or lipoprotein abnormalities.[47]
Differentiating Tests
- Clinical differentiation usually suffices.
- Consider laboratory tests such as liver enzymes and lipid panel.
Differentiating Signs/Symptoms
- Multiple open and closed comedones on the periorbital and malar areas, usually on older people with significant chronic sun exposure. Typically noninflammatory.
Differentiating Tests
- Clinical differentiation usually suffices.
- Skin biopsy shows increased elastic tissue with thickened, tortuous fibers in the upper and mid-dermis.[48]
Folliculitis (non gram-negative)
Differentiating Signs/Symptoms
- Common condition that manifests as erythematous papules and pustules, which are follicularly based.
- As opposed to acne, folliculitis often affects the trunk and extremities.
Differentiating Tests
- Clinical differentiation usually suffices.
- Pustular lesions that do not respond to typical acne antibiotics may be cultured.
Gram-negative folliculitis
Differentiating Signs/Symptoms
- Occurs in patients with acne treated with long-term antibiotics who subsequently develop pustules or nodules on the anterior nares, which then spreads. Can also occur in people after hot tub immersion, as well as in patients with HIV.
Differentiating Tests
- Lesions may be cultured to isolate the gram-negative bacteria if acneiform lesions do not respond to typical antibiotic regimen.
Differentiating Signs/Symptoms
- Firm yellowish-brown or red smooth papules periorbitally and characteristically on the eyelid skin.[49]
Differentiating Tests
- Diascopy reveals yellowish-brown lesions. Skin biopsy reveals caseating epithelioid cell granulomas.
Differentiating Signs/Symptoms
- White keratinaceous cysts that are found on the face, particularly on the eyelids. Lesions are fixed and persistent.
Differentiating Tests
- Skin biopsy shows small cysts derived from the infundibulum of the vellus hair.
Perioral dermatitis
Differentiating Signs/Symptoms
- Common perioral eruption of papules and pustules on an erythematous and/or scaling base, often the result of topical corticosteroid use. Localized symmetrically around the mouth, with a clear zone around the vermilion border.[50]
Differentiating Tests
- Clinical differentiation usually suffices.
Differentiating Signs/Symptoms
- Rapid onset of reddish or cyanotic erythema with abscesses, cysts, and occasionally sinus tracts. No comedones and no involvement of back or chest.[51]
Differentiating Tests
- Skin biopsy shows a grenz zone and mixed inflammatory infiltrate in the upper and mid-dermis, with extravasation of red blood cells and hemosiderin deposition.
Rosacea
Differentiating Signs/Symptoms
- More typically affects older people than does acne vulgaris, most often women aged 30 to 50 years.
- Various forms, but classically presents with background erythema and telangiectasias, and inflammatory papules and pustules occasionally superimposed.
- Environmental factors often act as triggers.
Differentiating Tests
- Clinical differentiation usually suffices. There is a lack of comedones in rosacea.
Differentiating Signs/Symptoms
- Noninflammatory small papules that occur primarily on the eyelids and upper cheeks, usually multiple.
- Disproportionately more prevalent in Japanese women.
Differentiating Tests
- Skin biopsy shows a dense fibrous stroma with dilated cystic spaces that have small comma-like tails resembling tadpoles.
Differentiating Signs/Symptoms
- Small, translucent, waxy papules distributed symmetrically over the central cheek, nose, and forehead.
- Multiple lesions associated with tuberous sclerosis.[52]
Differentiating Tests
- Skin biopsy shows dermal fibrosis and vascular proliferation and dilatation.
Criteria
- Mild: comedones are the main lesions. Papules and pustules may be present but are small and few in number (generally <10).
- Moderate: moderate numbers (10 to 40) of papules and pustules. Moderate numbers (10 to 40) of comedones are also present. Sometimes mild truncal disease.
- Moderately severe: numerous papules and pustules (40 to 100), usually with many comedones (40 to 100) and the occasional (up to 5) larger, deeper nodular inflamed lesions. Widespread affected areas usually involving face, chest, and back.
- Very severe: nodulocystic acne and acne conglobata with severe lesions; many large, painful nodular/pustular lesions along with many smaller papules, pustules, and comedones.
- Grade 0: clear skin with no inflammatory or noninflammatory lesions
- Grade 1: almost clear; rare noninflammatory lesions with no more than 1 small inflammatory lesion
- Grade 2: mild severity; greater than Grade 1; some noninflammatory lesions with no more than a few inflammatory lesions (papules/pustules only, no nodular lesions)
- Grade 3: moderate severity; greater than Grade 2; up to many noninflammatory lesions and may have some inflammatory lesions, but no more than 1 small nodular lesion
- Grade 4: severe; greater than Grade 3; up to many noninflammatory and inflammatory lesions, but no more than a few nodular lesions.
Treatment Approach
- Use only noncomedogenic products on skin (including makeup)
- Use nonalkaline (skin pH neutral or slightly acidic) synthetic detergent to cleanse skin twice daily
- Avoid using scrubs, astringents, fragranced products, or other irritants
- Avoid picking, squeezing, or scratching acne lesions, and
- Avoid getting hair products on the face.
Mild acne
Moderate acne
Severe acne or resistant to standard treatment
Women with hormonal involvement
Pregnant women
Treatment Options
not hormone-related (not pregnant)
mild acne: comedones only
topical retinoid or salicylic acid
Primary Options
- tretinoin topical
(0.01 to 0.1%) children >12 years of age and adults: apply to the affected area(s) once daily before bedtime or on alternate days
- tretinoin topical
- adapalene topical
(0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
- adapalene topical
- tazarotene topical
(0.05 to 0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
- tazarotene topical
- trifarotene topical
(0.005%) children ≥9 years of age and adults: apply to the affected area(s) once daily in the evening
- trifarotene topical
Secondary Options
- salicylic acid topical
(0.5 to 2% lotion, cream, cleanser, pads, solution, or toner) apply to the affected area(s) once daily
- salicylic acid topical
Comments
- Most topical retinoids produce some degree of fine peeling and erythema, especially early in treatment. Patients are started with lower potency and increased to higher potency if skin irritation is minimal.
- It is important that patients apply the medication to the whole treatment area (e.g., the entire face), not to specific acne lesions.
- These agents should be continued until the acne is completely clear.[57]
topical benzoyl peroxide
Primary Options
- benzoyl peroxide topical
(1 to 10%) consult product literature for guidance on dose
- benzoyl peroxide topical
Comments
- Topical benzoyl peroxide monotherapy may be considered as a second-line treatment for patients with mild acne with no inflammation, if other treatments are contraindicated or if the patient wishes to avoid using topical retinoids.[43] [53] Use of topical benzoyl peroxide may be associated with cutaneous irritation, such as erythema, pruritus, and skin burning.[58]
- Should be used until improvement is noted, then use can be gradually tapered and discontinued.
mild acne: with inflammatory papules/pustules
topical retinoid + topical antibiotic
Primary Options
- tretinoin topical
(0.01 to 0.1%) children >12 years of age and adults: apply to the affected area(s) once daily before bedtime or on alternate days
or
- adapalene topical
(0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
or
- tazarotene topical
(0.05% or 0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
or
- trifarotene topical
(0.005%) children ≥9 years of age and adults: apply to the affected area(s) once daily in the evening
AND
- clindamycin topical
(1% foam) children >12 years of age and adults: apply to the affected area(s) once daily; (1% gel, lotion, pledget or solution) children >12 years of age and adults: apply to the affected area(s) twice daily
or
- erythromycin topical
(2%) children and adults: apply to the affected area(s) twice daily
or
- minocycline topical
(4%) children ≥9 years of age and adults: apply to the affected area(s) once daily
or
- dapsone topical
(5%) children ≥12 years of age and adults: apply to the affected area(s) twice daily; reassess if no improvement in 12 weeks
- tretinoin topical
Comments
- Combination therapy is the mainstay of treatment.[61]
- Topical adapalene appears to be associated with a lower rate of toxicity than topical tretinoin. In one systematic review, 62% of patients using topical tretinoin experienced adverse events; the comparable figures for adapalene 0.1% and adapalene 0.3% were 19% and 40%, respectively.[64]
- Patients are started with a lower potency retinoid, which is increased to a higher potency if skin irritation is minimal. Topical adapalene is less likely to cause irritation than tretinoin.[83]
- Topical antibiotics may be tapered and discontinued once there is improvement. If no improvement is noted within 6 to 8 weeks, they should be discontinued and an alternative therapy considered.[57]
- Topical retinoids should be continued until the acne is completely clear.[57]
topical benzoyl peroxide
Primary Options
- benzoyl peroxide topical
(1 to 10%) consult product literature for guidance on dose
- benzoyl peroxide topical
Comments
- May be available in a proprietary combination product with either a topical retinoid or a topical antibiotic (e.g., adapalene/benzoyl peroxide, clindamycin/benzoyl peroxide, erythromycin/benzoyl peroxide). Adapalene/benzoyl peroxide has been shown to be effective for both inflammatory and noninflammatory lesions.[84] [85] [86] [87]
- Use of topical benzoyl peroxide may be associated with cutaneous irritation, such as erythema, pruritus, and skin burning.[58]
- Products should be applied at a different time to topical retinoids and topical antibiotics, if using separately, to avoid inactivation of any of the drugs.[72]
- Should be used until improvement is noted, then use can be gradually tapered and discontinued.
topical azelaic acid
Primary Options
- azelaic acid topical
(20%) children >12 years of age and adults: apply to the affected area(s) twice daily
- azelaic acid topical
Comments
topical benzoyl peroxide monotherapy
Primary Options
- benzoyl peroxide topical
(1 to 10%) consult product literature for guidance on dose
- benzoyl peroxide topical
Comments
- Topical benzoyl peroxide monotherapy may be an alternative first-line therapy for mild acne with inflammation if the patient wishes to avoid using a topical retinoid or antibiotic.[43] [53] Use of topical benzoyl peroxide may be associated with cutaneous irritation, such as erythema, pruritus, and skin burning.[58]
- Should be used until improvement is noted, then use can be gradually tapered and discontinued.
moderate acne: comedones only
topical retinoid
Primary Options
- tretinoin topical
(0.01 to 0.1%) children >12 years of age and adults: apply to the affected area(s) once daily before bedtime or on alternate days
- tretinoin topical
- adapalene topical
(0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
- adapalene topical
- tazarotene topical
(0.05% or 0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
- tazarotene topical
- trifarotene topical
(0.005%) children ≥9 years of age and adults: apply to the affected area(s) once daily in the evening
- trifarotene topical
Comments
- Moderate numbers (10 to 40) of papules and pustules are present; moderate numbers (10 to 40) of comedones are also present. Sometimes mild truncal disease.
- It is important that patients apply the medication to the whole treatment area (e.g., the entire face), not to specific acne lesions.
- Most topical retinoids produce some degree of fine peeling and erythema, especially early in treatment. Start with a lower potency and increase to a higher potency if skin irritation is minimal. Topical adapalene is less likely to cause irritation than tretinoin.[83]
- Topical retinoids should be continued until the acne is completely clear.[57]
topical benzoyl peroxide
Primary Options
- benzoyl peroxide topical
(1 to 10%) consult product literature for guidance on dose
- benzoyl peroxide topical
Comments
- Use of topical benzoyl peroxide may be associated with cutaneous irritation, such as erythema, pruritus, and skin burning.[58]
- Should be used until improvement is noted, then use can be gradually tapered and discontinued.
moderate acne: with inflammatory papules/pustules
topical retinoid + oral antibiotic
Primary Options
- tretinoin topical
(0.01 to 0.1%) children >12 years of age and adults: apply to the affected area(s) once daily before bedtime or on alternate days
or
- adapalene topical
(0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
or
- tazarotene topical
(0.05% or 0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
or
- trifarotene topical
(0.005%) children ≥9 years of age and adults: apply to the affected area(s) once daily in the evening
AND
- tetracycline
adolescents and adults: 250-500 mg orally twice daily for 2-3 months, followed by 250-500 mg once daily for 1-2 months
or
- minocycline
adolescents and adults: 50-100 mg orally (regular release) twice daily for 2-3 months, followed by 50-100 mg once daily for 1- 2 months
or
- doxycycline
50-100 mg orally twice daily for 2-3 months, followed by 50-100 mg once daily for 1-2 months
or
- sarecycline
body weight <55 kg: 60 mg orally once daily for 12 weeks; body weight 55-84 kg: 100 mg orally once daily for 12 weeks; body weight 85-136 kg: 150 mg orally once daily for 12 weeks
- tretinoin topical
Secondary Options
- tretinoin topical
(0.01 to 0.1%) children >12 years of age and adults: apply to the affected area(s) once daily before bedtime or on alternate days
or
- adapalene topical
(0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
or
- tazarotene topical
(0.05% or 0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
or
- trifarotene topical
(0.005%) children ≥9 years of age and adults: apply to the affected area(s) once daily in the evening
AND
- erythromycin base
500 mg orally twice daily for 2-3 months, followed by 500 mg once daily for 1-2 months
- tretinoin topical
Comments
- Usually treated with a combination of an oral antibiotic and a topical retinoid.[43]
- Oral antibiotics are typically administered for 12 weeks to reduce the risk for development of bacterial resistance.[43] [53] The most commonly used systemic antibiotics include tetracyclines (e.g., doxycycline, minocycline, tetracycline, sarecycline) and macrolides (e.g., erythromycin). Oral antibiotics may cause systemic adverse effects.
- Monotherapy with systemic antibiotics is not recommended.[43] [53] US guidelines recommend concomitant topical therapy with benzoyl peroxide or a retinoid with systemic antibiotics.[53] UK guidance recommends a topical retinoid, benzoyl peroxide, and oral antibiotic for the treatment of moderate to severe acne vulgaris.[43] Use of topical benzoyl peroxide may be associated with cutaneous irritation, such as erythema, pruritus, and skin burning.[58]
- Topical retinoids should be continued until the acne is completely clear.[57]
topical benzoyl peroxide
Primary Options
- benzoyl peroxide topical
(1 to 10%) consult product literature for guidance on dose
- benzoyl peroxide topical
Comments
- US guidelines recommend topical therapy with benzoyl peroxide for maintenance after completion of oral antibiotic therapy.[53]
- May be available in a proprietary combination product with either a topical retinoid or a topical antibiotic (e.g., adapalene/benzoyl peroxide, clindamycin/benzoyl peroxide, erythromycin/benzoyl peroxide). Adapalene/benzoyl peroxide has been shown to be effective for both inflammatory and noninflammatory lesions.[84] [85] [86] [87]
- Topical adapalene appears to be associated with a lower rate of toxicity than topical tretinoin. In one systematic review, 62% of patients using topical tretinoin experienced adverse events; the comparable figures for adapalene 0.1% and adapalene 0.3% were 19% and 40%, respectively.[64] Use of topical benzoyl peroxide may be associated with cutaneous irritation, such as erythema, pruritus, and skin burning.[58]
- Products should be applied at a different time to topical retinoids and topical antibiotics, if using separately, to avoid inactivation of any of the drugs.[72]
- Should be used until improvement is noted, then use can be gradually tapered and discontinued.
topical azelaic acid
Primary Options
- azelaic acid topical
(20%) children >12 years of age and adults: apply to the affected area(s) twice daily
- azelaic acid topical
Comments
- Azelaic acid, an antimicrobial with mild comedolytic and anti-inflammatory properties, may also be considered as an adjunct to systemic antibiotic therapy for the treatment of moderate to severe inflammatory acne.[43] [53][65] Azelaic acid can be helpful for the treatment of postinflammatory dyspigmentation.
- Should be used until improvement is noted, then use can be gradually tapered and discontinued.
topical benzoyl peroxide monotherapy
Primary Options
- benzoyl peroxide topical
(1 to 10%) consult product literature for guidance on dose
- benzoyl peroxide topical
Comments
- Should be used until improvement is noted, then use can be gradually tapered and discontinued.
severe or resistant acne
oral retinoid
Primary Options
- isotretinoin
children ≥12 years of age: 0.5 to 1 mg/kg/day orally given in 2 divided doses; adults: 0.5 to 2 mg/kg/day orally given in 2 divided doses
- isotretinoin
- isotretinoin lidose
children ≥12 years of age: 0.5 to 1 mg/kg/day orally given in 2 divided doses; adults: 0.5 to 2 mg/kg/day orally given in 2 divided doses
- isotretinoin lidose
- isotretinoin micronized
children ≥12 years of age: 0.4 to 0.8 mg/kg/day orally given in 2 divided doses; adults: 0.4 to 1.6 mg/kg/day orally given in 2 divided doses
- isotretinoin micronized
Comments
- Severe acne is defined by numerous papules and pustules (40 to 100), usually with many comedones (40 to 100) and the occasional (up to 5) larger, deeper nodular inflamed lesions may be present in moderately severe acne.[5] Widespread affected areas are evident, usually involving face, chest, and back.
- Very severe acne is defined by nodulocystic acne and acne conglobata with severe lesions; many large, painful nodular/pustular lesions along with many smaller papules, pustules, and comedones.[5]
- Adverse effects can be severe, and regular monitoring during treatment is required.[72] Severe headaches, decreased night vision, significant liver enzyme or lipid elevations, or signs of adverse psychiatric events necessitate prompt discontinuation. Elevated serum cholesterol, triglycerides, and transaminases, have been reported in some patients taking oral isotretinoin. Lipid panel and liver function tests should be monitored regularly.[53] Routine monitoring of complete blood cell counts is not recommended.[53]
- Isotretinoin is teratogenic; all women should have a pregnancy test before starting the drug and subsequently monthly while taking it. In the US, isotretinoin can only be prescribed through the iPledge risk management program.iPledge system (for isotretinoin prescribing)
- Results from studies investigating whether isotretinoin increases the incidence of depression and/or suicidal ideation are conflicting; signs and symptoms of depression should be monitored during and after treatment.[53] [73] [74] Depressive symptoms often improve after treatment with isotretinoin, as well as with other therapies, as the acne symptoms improve.[75] [76]
- Lidose and micronized formulations of isotretinoin improve oral bioavailability, pharmacologic bioactivity, and increase efficacy in patients who are unwilling/unable to take regular isotretinoin with a high fat/calorie meal.[90]
oral corticosteroid
Primary Options
- prednisone
40-60 mg/day orally
- prednisone
Comments
- Oral corticosteroid therapy (e.g., prednisone) may be used in conjunction with isotretinoin, to treat the systemic and cutaneous manifestations of acne fulminans and for prevention and treatment of isotretinoin-induced acne flare, respectively.[43] [53] In these instances, oral corticosteroids are generally used for 1 to 4 months to avoid relapse.[9]
- Oral corticosteroids are always used in acne fulminans. Dose needs careful tapering to discontinue.
intralesional corticosteroid injection
hormone-related (women, not pregnant)
oral hormonal therapy
Primary Options
Secondary Options
Comments
- Hormonal therapy may be used in women experiencing acne flares associated with menstrual periods; they should be pursued only if other treatments are ineffective.[77]
- Hormonal therapy is helpful in women with established ovarian or adrenal hyperandrogenism and in those with polycystic ovary syndrome.
- Treatment may require specialist endocrinologist involvement.[77]
inflammatory
topical retinoid + oral antibiotic
Primary Options
- tretinoin topical
(0.01 to 0.1%) children >12 years of age and adults: apply to the affected area(s) once daily before bedtime or on alternate days
or
- adapalene topical
(0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
or
- tazarotene topical
(0.05% or 0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
or
- trifarotene topical
(0.005%) children ≥9 years of age and adults: apply to the affected area(s) once daily in the evening
AND
- tetracycline
adolescents and adults: 250-500 mg orally twice daily for 2-3 months, followed by 250-500 mg once daily for 1-2 months
or
- minocycline
adolescents and adults: 50-100 mg orally (regular release) twice daily for 2-3 months, followed by 50-100 mg once daily for 1- 2 months
or
- doxycycline
50-100 mg orally twice daily for 2-3 months, followed by 50-100 mg once daily for 1-2 months
or
- sarecycline
body weight <55 kg: 60 mg orally once daily for 12 weeks; body weight 55-84 kg: 100 mg orally once daily for 12 weeks; body weight 85-136 kg: 150 mg orally once daily for 12 weeks
- tretinoin topical
Secondary Options
- tretinoin topical
(0.01 to 0.1%) children >12 years of age and adults: apply to the affected area(s) once daily before bedtime or on alternate days
or
- adapalene topical
(0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
or
- tazarotene topical
(0.05% or 0.1%) children >12 years of age and adults: apply to the affected area(s) every evening
or
- trifarotene topical
(0.005%) children ≥9 years of age and adults: apply to the affected area(s) once daily in the evening
AND
- erythromycin base
500 mg orally twice daily for 2-3 months, followed by 500 mg once daily for 1-2 months
- tretinoin topical
Comments
- For best results, consider the combination of oral antibiotics and topical retinoids. Topical retinoids include tretinoin, adapalene, tazarotene, and trifarotene.[54] Patients are started with a lower potency of a topical retinoid, and increased to a higher potency if skin irritation is minimal. Topical adapalene is less likely to cause irritation than tretinoin.[83]
- Oral antibiotics are typically administered for at least 6 to 8 weeks. They should ideally be used for a maximum of 3 months, and always in combination with a retinoid, benzoyl peroxide, or both of these agents. When antibiotics need to be used for longer than 3 months (some people require indefinite antibiotic therapy), benzoyl peroxide should always be used in conjunction with the antibiotic.[68] The most commonly used systemic antibiotics include tetracyclines (e.g., doxycycline, minocycline, tetracycline, sarecycline) and macrolides (e.g., erythromycin).[67] Monotherapy with systemic antibiotics is not recommended, due to the potential for developing resistance.[57] [68] [69]
- Topical retinoids should be continued until the acne is completely clear.[57]
topical benzoyl peroxide
Primary Options
- benzoyl peroxide topical
(1 to 10%) consult product literature for guidance on dose
- benzoyl peroxide topical
Comments
- May be available in a proprietary combination product with either a topical retinoid or a topical antibiotic (e.g., adapalene/benzoyl peroxide, clindamycin/benzoyl peroxide, erythromycin/benzoyl peroxide). Adapalene/benzoyl peroxide has been shown to be effective for both inflammatory and noninflammatory lesions.[84] [85] [86] [87]
- Topical adapalene appears to be associated with a lower rate of toxicity than topical tretinoin. In one systematic review, 62% of patients using topical tretinoin experienced adverse events; the comparable figures for adapalene 0.1% and adapalene 0.3% were 19% and 40%, respectively.[64] Use of topical benzoyl peroxide may be associated with cutaneous irritation, such as erythema, pruritus, and skin burning.[58]
- Products should be applied at a different time to topical retinoids and topical antibiotics, if using separately, to avoid inactivation of any of the drugs.[72]
- Should be used until improvement is noted, then use can be gradually tapered and discontinued.
topical azaleic acid
Primary Options
- azelaic acid topical
(20%) children >12 years of age and adults: apply to the affected area(s) twice daily
- azelaic acid topical
Comments
- An antimicrobial with mild comedolytic and anti-inflammatory properties.[65] It can be helpful in reducing postinflammatory hyperpigmentation.
- Should be used until improvement is noted, then use can be gradually tapered and discontinued.
pregnant
topical antibiotic
Primary Options
- clindamycin topical
(1% foam) adults: apply to the affected area(s) once daily; (1% gel, lotion, pledget or solution) adults: apply to the affected area(s) twice daily
- clindamycin topical
- erythromycin topical
(2%) adults: apply to the affected area(s) twice daily
- erythromycin topical
- azelaic acid topical
(20%) adults: apply to the affected area(s) twice daily
- azelaic acid topical
Comments
- In pregnant women with severe acne, only a few topical agents are considered safe to use in pregnancy, including clindamycin, erythromycin, and azelaic acid.
- Topical antibiotics may be tapered and discontinued once improvement is noted. If no improvement is noted within 6 to 8 weeks, they should be discontinued and an alternative therapy considered.[57] Azelaic acid should be used until improvement is noted, then use can be gradually tapered and discontinued.
Emerging Tx
Clascoterone
Laser and light treatments
Prevention
Secondary Prevention
- Use only noncomedogenic products on skin (include makeup)
- Use nonalkaline (skin pH neutral or slightly acidic) synthetic detergent to cleanse skin twice daily
- Avoid using scrubs, astringents, fragranced products, or other irritants
- Avoid picking, squeezing, or scratching acne lesions, and
- Avoid getting hair products on the face.
Follow-Up Overview
Prognosis
Complications
Citations
National Institute for Health and Care Excellence. Acne vulgaris: management. May 2023 [internet publication].[Full Text]
European Dermatology Forum. EDF guidelines and consensus statements. 2016 [internet publication].[Full Text]
Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016 May;74(5):945-73;e33.[Abstract][Full Text]
Gollnick H, Cunliffe W, Berson D, et al. Management of acne: a report from a global alliance to improve outcomes in acne. J Am Acad Dermatol. 2003 Jul;49(1 suppl):S1-37.[Abstract]
1. Karimkhani C, Dellavalle RP, Coffeng LE, et al. Global skin disease morbidity and mortality: an update from the Global Burden of Disease Study 2013. JAMA Dermatol. 2017 May 1;153(5):406-12.[Abstract]
2. Samuels DV, Rosenthal R, Lin R, et al. Acne vulgaris and risk of depression and anxiety: a meta-analytic review. J Am Acad Dermatol. 2020 Aug;83(2):532-41.[Abstract]
3. Layton AM, Eady EA, Thiboutot DM, et al. Identifying what to measure in acne clinical trials: first steps towards development of a core outcome set. J Invest Dermatol. 2017 Aug;137(8):1784-6.[Full Text]
4. Thiboutot DM, Layton AM, Chren MM, et al. Assessing effectiveness in acne clinical trials: steps towards a core outcome measure set. Br J Dermatol. 2019 Oct;181(4):700-6.[Abstract]
5. White GM. Recent findings in the epidemiologic evidence, classification, and subtypes of acne vulgaris. J Am Acad Dermatol. 1998 Aug;39(2 Pt 3):S34-7.[Abstract]
6. US Food and Drug Administration. Acne vulgaris: establishing effectiveness of drugs intended for treatment. May 2018 [internet publication].[Full Text]
7. Burke BM, Cunliffe WJ. The assessment of acne vulgaris - the Leeds technique. Br J Dermatol. 1984 Jul;111(1):83-92.[Abstract]
8. Screening and Management of the Hyperandrogenic Adolescent: ACOG Committee Opinion, Number 789. Obstet Gynecol. 2019 Oct;134(4):e106-e114.[Abstract][Full Text]
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13. Chen H, Zhang TC, Yin XL, et al. Magnitude and temporal trend of acne vulgaris burden in 204 countries and territories from 1990 to 2019: an analysis from the Global Burden of Disease Study 2019. Br J Dermatol. 2022 Apr;186(4):673-83.[Abstract]
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21. Leyden JJ, McGinley KJ, Mills OH, et al. Propionibacterium levels in patients with and without acne vulgaris. J Invest Dermatol. 1975 Oct;65(4):382-4.[Abstract]
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23. Walton S, Wyatt EH, Cunliffe WJ. Genetic control of sebum excretion in acne - a twin study. Br J Dermatol. 1988 Mar;118(3):393-6.[Abstract]
24. Bataille V, Snieder H, MacGregor AJ, et al. The influence of genetics and environmental factors in the pathogenesis of acne: a twin study of acne in women. J Invest Dermatol. 2002 Dec;119(6):1317-22.[Abstract]
25. Common JEA, Barker JN, van Steensel MAM. What does acne genetics teach us about disease pathogenesis? Br J Dermatol. 2019 Oct;181(4):665-676.[Abstract][Full Text]
26. Petridis C, Navarini AA, Dand N, et al. Genome-wide meta-analysis implicates mediators of hair follicle development and morphogenesis in risk for severe acne. Nat Commun. 2018 Dec 12;9(1):5075.[Abstract][Full Text]
27. Navarini AA, Simpson MA, Weale M, et al. Genome-wide association study identifies three novel susceptibility loci for severe Acne vulgaris. Nat Commun. 2014 Jun 13;5:4020.[Abstract][Full Text]
28. Knutson DD. Ultrastructural observations in acne vulgaris: the normal sebaceous follicle and acne lesions. J Invest Dermatol. 1974 Mar;62:288-307.[Abstract]
29. Scott DG, Cunliffe WJ, Gowland G. Activation of complement - a mechanism for the inflammation in acne. Br J Dermatol. 1979 Sep;101(3):315-20.[Abstract]
30. Eichenfield DZ, Sprague J, Eichenfield LF. Management of acne vulgaris: a review. JAMA. 2021 Nov 23;326(20):2055-67.[Abstract]
31. Radi R, Gold S, Acosta JP, et al. Treating acne in transgender persons receiving testosterone: a practical guide. Am J Clin Dermatol. 2022 Mar;23(2):219-29.[Abstract][Full Text]
32. Dai R, Hua W, Chen W, et al. The effect of milk consumption on acne: a meta-analysis of observational studies. J Eur Acad Dermatol Venereol. 2018 Dec;32(12):2244-53.[Abstract]
33. Aghasi M, Golzarand M, Shab-Bidar S, et al. Dairy intake and acne development: a meta-analysis of observational studies. Clin Nutr. 2019 Jun;38(3):1067-75.[Abstract]
34. Penso L, Touvier M, Deschasaux M, et al. Association between adult acne and dietary behaviors: findings from the NutriNet-Santé prospective cohort study. JAMA Dermatol. 2020 Aug 1;156(8):854-62.[Abstract][Full Text]
35. Kwon HH, Yoon JY, Hong JS, et al. Clinical and histological effect of a low glycaemic load diet in treatment of acne vulgaris in Korean patients: a randomized, controlled trial. Acta Derm Venereol. 2012 May;92(3):241-6.[Abstract][Full Text]
36. Smith R, Mann N, Mäkeläinen H, et al. A pilot study to determine the short-term effects of a low glycemic load diet on hormonal markers of acne: a nonrandomized, parallel, controlled feeding trial. Mol Nutr Food Res. 2008 Jun;52(6):718-26.[Abstract]
37. Smith RN, Braue A, Varigos GA, et al. The effect of a low glycemic load diet on acne vulgaris and the fatty acid composition of skin surface triglycerides. J Dermatol Sci. 2008 Apr;50(1):41-52.[Abstract]
38. Juhl CR, Bergholdt HKM, Miller IM, et al. Dairy intake and acne vulgaris: a systematic review and meta-analysis of 78,529 children, adolescents, and young adults. Nutrients. 2018 Aug 9;10(8):1049.[Abstract][Full Text]
39. Strauss JS, Pochi PE. Effect of cyclic progestin-estrogen therapy on sebum and acne in women. JAMA. 1964 Nov 30;190(9):815-9.[Abstract]
40. Yang CS, Teeple M, Muglia J, et al. Inflammatory and glandular skin disease in pregnancy. Clin Dermatol. 2016 May-Jun;34(3):335-43.[Abstract]
41. Aizawa H, Niimura M. Elevated serum insulin-like growth factor-1 (IGF-1) levels in women with postadolescent acne. J Dermatol. 1995 Apr;22(4):249-52.[Abstract]
42. Yamamoto O, Tokura Y. Photocontact dermatitis and chloracne: two major occupational and environmental skin diseases induced by different actions of halogenated chemicals. J Dermatol Sci. 2003 Aug;32(2):85-94.[Abstract]
43. National Institute for Health and Care Excellence. Acne vulgaris: management. May 2023 [internet publication].[Full Text]
44. European Dermatology Forum. EDF guidelines and consensus statements. 2016 [internet publication].[Full Text]
45. Maranda EL, Simmons BJ, Nguyen AH, et al. Treatment of acne keloidalis nuchae: a systematic review of the literature. Dermatol Ther (Heidelb). 2016 Sep;6(3):363-78.[Abstract][Full Text]
46. Khumalo NP, Jessop S, Ehrlich R. Prevalence of cutaneous adverse effects of hairdressing. Arch Dermatol. 2006 Mar;142(3):377-83.[Abstract]
47. Rosas Vazquez E, Campos Macias P, Ochoa Tirado JG, et al. Chloracne in the 1990s. Int J Dermatol. 1996 Sep;35(9):643-5.[Abstract]
48. Lewis KG, Bercovitch L, Dill SW, et al. Acquired disorders of elastic tissue: Part I. increased elastic tissue and solar elasotic syndromes. J Am Acad Dermatol. 2004 Jul;51(1):1-21;quiz 22-4.[Abstract]
49. Sehgal VN, Srivastava G, Aggarwal AK, et al. Lupus miliaris disseminatus faciei part II: an overview. Skinmed. 2005 Jul-Aug;4(4):234-8.[Abstract]
50. Hengge UR, Ruzicka T, Schwartz RA, et al. Adverse effects of topical glucocorticosteroids. J Am Acad Dermatol. 2006 Jan;54(1):1-15;quiz 16-8.[Abstract]
51. Plewig G, Jansen T, Kligman AM. Pyoderma faciale. A review and report of 20 additional cases: is it rosacea? Arch Dermatol. 1992 Dec;128(12):1611-7.[Abstract]
52. Schwartz RA, Fernandez G, Kotulska K, et al. Tuberous sclerosis complex: advances in diagnosis, genetics, and management. J Am Acad Dermatol. 2007 Aug;57(2):189-202.[Abstract]
53. Zaenglein AL, Pathy AL, Schlosser BJ, et al. Guidelines of care for the management of acne vulgaris. J Am Acad Dermatol. 2016 May;74(5):945-73;e33.[Abstract][Full Text]
54. Kawashima M, Harada S, Loesche C, et al. Adapalene gel 0.1% is effective and safe for Japanese patients with acne vulgaris: a randomized, multicenter, investigator-blinded, controlled study. J Dermatol Sci. 2008 Mar;49(3):241-8.[Abstract]
55. Tan J, Thiboutot D, Popp G, et al. Randomized phase 3 evaluation of trifarotene 50 mcg/g cream treatment of moderate facial and truncal acne. J Am Acad Dermatol. 2019 Jun;80(6):1691-9.[Abstract][Full Text]
56. Bell KA, Brumfiel CM, Haidari W, et al. Trifarotene for the treatment of facial and truncal acne. Ann Pharmacother. 2021 Jan;55(1):111-6.[Abstract][Full Text]
57. Thiboutot DM, Dréno B, Abanmi A, et al. Practical management of acne for clinicians: an international consensus from the Global Alliance to Improve Outcomes in Acne. J Am Acad Dermatol. 2018 Feb;78(2 suppl 1):S1-23;e1.[Abstract]
58. Yang Z, Zhang Y, Lazic Mosler E, et al. Topical benzoyl peroxide for acne. Cochrane Database Syst Rev. 2020 Mar 16;3:CD011154.[Abstract][Full Text]
59. Shalita AR. Treatment of mild and moderate acne vulgaris with salicylic acid in an alcohol-detergent vehicle. Cutis. 1981 Nov;28(5):556-8;561.[Abstract]
60. Liu H, Yu H, Xia J, et al. Topical azelaic acid, salicylic acid, nicotinamide, sulphur, zinc and fruit acid (alpha-hydroxy acid) for acne. Cochrane Database Syst Rev. 2020 May 1;5:CD011368.[Abstract][Full Text]
61. Seidler EM, Kimball AB. Meta-analysis comparing efficacy of benzoyl peroxide, clindamycin, benzoyl peroxide with salicylic acid, and combination benzoyl peroxide/clindamycin in acne. J Am Acad Dermatol. 2010 Jul;63(1):52-62.[Abstract]
62. Gold LS, Dhawan S, Weiss J, et al. A novel topical minocycline foam for the treatment of moderate-to-severe acne vulgaris: results of 2 randomized, double-blind, phase 3 studies. J Am Acad Dermatol. 2019 Jan;80(1):168-77.[Abstract]
63. Raoof TJ, Hooper D, Moore A, et al. Efficacy and safety of a novel topical minocycline foam for the treatment of moderate to severe acne vulgaris: a phase 3 study. J Am Acad Dermatol. 2020 Apr;82(4):832-7.[Abstract][Full Text]
64. Kolli SS, Pecone D, Pona A, et al. Topical retinoids in acne vulgaris: a systematic review. Am J Clin Dermatol. 2019 Jun;20(3):345-65.[Abstract]
65. Graupe K, Cunliffe W, Gollnick H, et al. Efficacy and safety of topical azelaic acid (20% cream): an overview of results from European clinical trials and experimental reports. Cutis. 1996 Jan;57(1 suppl):20-35.[Abstract]
66. Harper JC, Baldwin H, Stein Gold L, et al. Efficacy and tolerability of a novel tretinoin 0.05% lotion for the once-daily treatment of moderate or severe acne vulgaris in adult females. J Drugs Dermatol. 2019 Nov 1;18(11):1147-54.[Abstract]
67. Barbieri JS. Temporal trends in the use of systemic medications for acne from 2017 to 2020. JAMA Dermatol. 2023 Oct 1;159(10):1135-6.
68. Walsh TR, Efthimiou J, Dreno B. Systematic review of antibiotic resistance in acne: an increasing topical and oral threat. Lancet Infect Dis. 2016 Mar;16(3):e23-33.[Abstract]
69. Ochsendorf F. Systemic antibiotic therapy of acne vulgaris [in German]. J Dtsch Dermatol Ges. 2010 Mar;8(suppl 1):S31-46.[Abstract]
70. Costa CS, Bagatin E, Martimbianco ALC, et al. Oral isotretinoin for acne. Cochrane Database Syst Rev. 2018 Nov 24;11:CD009435.[Abstract][Full Text]
71. Huang CY, Chang IJ, Bolick N, et al. Comparative efficacy of pharmacological treatments for acne vulgaris: a network meta-analysis of 221 randomized controlled trials. Ann Fam Med. 2023 Jul-Aug;21(4):358-69.[Abstract][Full Text]
72. Gollnick H, Cunliffe W, Berson D, et al. Management of acne: a report from a global alliance to improve outcomes in acne. J Am Acad Dermatol. 2003 Jul;49(1 suppl):S1-37.[Abstract]
73. Goldsmith LA, Bolognia JL, Callen JP, et al; American Academy of Dermatology. American Academy of Dermatology Consensus Conference on the safe and optimal use of isotretinoin: summary and recommendations. J Am Acad Dermatol. 2004 Jun;50(6):900-6.[Abstract]
74. Goodfield MJ, Cox NH, Bowser A, et al. Advice on the safe introduction and continued use of isotretinoin in acne in the U.K. 2010. Br J Dermatol. 2010 Jun;162(6):1172-9.[Abstract][Full Text]
75. Huang YC, Cheng, YC. Isotretinoin treatment for acne and risk of depression: a systematic review and meta-analysis. J Am Acad Dermatol. 2017 Jun;76(6):1068-76;e9.[Abstract]
76. Li C, Chen J, Wang W, et al. Use of isotretinoin and risk of depression in patients with acne: a systematic review and meta-analysis. BMJ Open. 2019 Jan 21;9(1):e021549.[Abstract][Full Text]
77. Arowojolu AO, Gallo MF, Lopez LM, et al. Combined oral contraceptive pills for treatment of acne. Cochrane Database Syst Rev. 2012 Jul 11;(7):CD004425.[Abstract][Full Text]
78. Fraison E, Kostova E, Moran LJ, et al. Metformin versus the combined oral contraceptive pill for hirsutism, acne, and menstrual pattern in polycystic ovary syndrome. Cochrane Database Syst Rev. 2020 Aug 13;8:CD005552.[Abstract][Full Text]
79. Zouboulis CC, Rabe T. Hormonal antiandrogens in acne treatment [in German]. J Dtsch Dermatol Ges. 2010 Mar;8(suppl 1):S60-74.[Abstract]
80. Barbieri JS, Choi JK, Mitra N, et al. Frequency of treatment switching for spironolactone compared to oral tetracycline-class antibiotics for women with acne: a retrospective cohort study 2010-2016. J Drugs Dermatol. 2018 Jun 1;17(6):632-8.[Abstract]
81. Santer M, Lawrence M, Renz S, et al. Effectiveness of spironolactone for women with acne vulgaris (SAFA) in England and Wales: pragmatic, multicentre, phase 3, double blind, randomised controlled trial. BMJ. 2023 May 16;381:e074349.[Abstract][Full Text]
82. Fan H, Gilbert R, O'Callaghan F, et al. Associations between macrolide antibiotics prescribing during pregnancy and adverse child outcomes in the UK: population based cohort study. BMJ. 2020 Feb 19;368:m331.[Abstract][Full Text]
83. Cunliffe WJ, Poncet M, Loesche C, et al. A comparison of the efficacy and tolerability of adapalene 0.1% gel versus tretinoin 0.025% gel in patients with acne vulgaris: a meta-analysis of five randomized trials. Br J Dermatol. 1998 Oct;139 Suppl 52:48-56.[Abstract]
84. Thiboutot DM, Weiss J, Bucko A, et al; Adapalene-BPO Study Group. Adapalene-benzoyl peroxide, a fixed-dose combination for the treatment of acne vulgaris: results of a multicenter, randomized double-blind, controlled study. J Am Acad Dermatol. 2007 Nov;57(5):791-9.[Abstract]
85. Gollnick HP, Draelos Z, Glenn MJ. Adapalene-benzoyl peroxide, a unique fixed-dose combination topical gel for the treatment of acne vulgaris: a transatlantic, randomized, double-blind, controlled study in 1670 patients. Br J Dermatol. 2009 Nov;161(5):1180-9.[Abstract]
86. Poulin YS, Sanchez NP, Bucko A, et al. A 6-month maintenance therapy with adapalene-benzoyl peroxide gel prevents relapse and continuously improves efficacy among patients with severe acne vulgaris: results of a randomized controlled trial. Br J Dermatol. 2011 Jun;164(6):1376-82.[Abstract]
87. Friedman A, Waite K, Brandt S, et al. Accelerated onset of action and increased tolerability in treating acne with a fixed-dose combination gel. J Drugs Dermatol. 2016 Feb;15(2):231-6.[Abstract]
88. Zouboulis CC, Piquero-Martin J. Update and future of systemic acne treatment. Dermatology. 2003;206(1):37-53.[Abstract]
89. Simonart T, Dramaix M, De Maertelaer V. Efficacy of tetracyclines in the treatment of acne vulgaris: a review. Br J Dermatol. 2008 Feb;158(2):208-16.[Abstract]
90. Bellomo R, Brunner M, Tadjally E. New formulations of isotretinoin for acne treatment: expanded options and clinical implications. J Clin Aesthet Dermatol. 2021 Dec;14(12 suppl 1):S18-23.[Abstract][Full Text]
91. Muhlemann MF, Carter GD, Cream JJ, et al. Oral spironolactone: an effective treatment for acne vulgaris in women. Br J Dermatol. 1986 Aug;115(2):227-32.[Abstract]
92. Hebert A, Thiboutot D, Stein Gold L, et al. Efficacy and safety of topical clascoterone cream, 1%, for treatment in patients with facial acne: two phase 3 randomized clinical trials. JAMA Dermatol. 2020 Jun 1;156(6):621-30.[Abstract][Full Text]
93. Barbaric J, Abbott R, Posadzki P, et al. Light therapies for acne. Cochrane Database Syst Rev. 2016 Sep 27;9(9):CD007917.[Abstract][Full Text]
94. Boen M, Brownell J, Patel P, et al. The role of photodynamic therapy in acne: an evidence-based review. Am J Clin Dermatol. 2017 Jun;18(3):311-21.[Abstract]
95. Ong MW, Bashir SJ. Fractional laser resurfacing for acne scars: a review. Br J Dermatol. 2012 Jun;166(6):1160-9.[Abstract]
96. Ansari F, Sadeghi-Ghyassi F, Yaaghoobian B. The clinical effectiveness and cost-effectiveness of fractional CO2 laser in acne scars and skin rejuvenation: a meta-analysis and economic evaluation. J Cosmet Laser Ther. 2018 Aug;20(4):248-51.[Abstract]
97. Bhargava S, Cunha PR, Lee J, et al. Acne scarring management: systematic review and evaluation of the evidence. Am J Clin Dermatol. 2018 Aug;19(4):459-77.[Abstract]
98. Harris AG, Naidoo C, Murrell DF. Skin needling as a treatment for acne scarring: an up-to-date review of the literature. Int J Womens Dermatol. 2015 Apr 10;1(2):77-81.[Abstract][Full Text]
99. Bonati LM, Epstein GK, Strugar TL. Microneedling in all skin types: a review. J Drugs Dermatol. 2017 Apr 1;16(4):308-13.[Abstract]
100. Alster TS, Graham PM. Microneedling: a review and practical guide. Dermatol Surg. 2018 Mar;44(3):397-404.[Abstract]
101. Ramaut L, Hoeksema H, Pirayesh A, et al. Microneedling: where do we stand now? A systematic review of the literature. J Plast Reconstr Aesthet Surg. 2018 Jan;71(1):1-14.[Abstract]
102. American Academy of Dermatology Association. Isotretinoin: the truth about side effects. Dec 2020 [internet publication].[Full Text]
Key Articles
Other Online Resources
Referenced Articles
Guidelines
Treatment
Summary
A comprehensive overview of the management of this condition.Published by
American Academy of Dermatology
Published
2016
Summary
Developed to help healthcare professionals provide optimal therapy to people with acne.Published by
European Dermatology Forum
Published
2016
Summary
Evidence-based recommendations for the management of acne vulgaris.Published by
National Institute for Health and Care Excellence
Published
2023